Tolterodine: Experience-sharing interview with Dr Colin Teo
1. What are your preferred medical therapies for managing overactive bladder (OAB) and why?
Behavioural interventions, such as bladder training and pelvic floor muscle training, are considered to be the first-line treatment for OAB and these therapies are effective for managing mild symptoms in patients with the disorder. Specific antimuscarinic agents, such as tolterodine, are considered to be a second-line treatment for OAB.1
However, the most effective approach is using behavioural interventions in combination with pharmacotherapy.2 Evidence suggests that behavioural interventions, such as bladder training, can augment the effectiveness of antimuscarinic drugs such as tolterodine (Figure 1).2
2. What is your criteria for prescribing tolterodine to your patients?
In patients with severe OAB symptoms, pharmacotherapy can be initiated immediately after the first examination. Tolterodine has been in use for a long time and has proven efficacy in treating OAB.3 Therefore, tolterodine is the preferred drug of choice for many clinicians.
Tolterodine is often prescribed as a drug treatment for OAB because it:
- Is relatively inexpensive
- Is easily accessible for many patients
- Has relatively few side effects compared with other antimuscarinic agents and the side effects do not significantly affect a patient’s quality of life4
- Can be dose-titrated to alleviate minor side effects, such as dry mouth1,5
- Has few drug interactions and can be administered concomitantly with other medications,5 which is particularly important for elderly patients.
3. How effective is tolterodine in your patients?
The efficacy of immediate- and extended-release formulations (IR and ER, respectively) of tolterodine has been extensively studied and shown to significantly decrease the number of urgency and incontinence episodes.3 In some patients, therapeutic benefit, including fewer episodes of urgency and incontinence, has been reported with tolterodine ER after 1 week of treatment.6 However, tolterodine generally exerts its therapeutic effects after approximately 4 weeks.5
4. What is the safety profile of tolterodine in your patients?
All antimuscarinic drugs produce side effects, including dry mouth, and in that regard tolterodine is no different.1,5 However, many patients do not consider dry mouth to be a significant burden compared with experiencing the symptoms of OAB.
Constipation is considered more problematic, particularly for older patients, but patients value the benefit of tolterodine to the extent that they are often willing to tolerate any treatment-related constipation.7 Additionally, a meta-analysis of randomized controlled trials found that tolterodine IR and ER had fewer side effects than oxybutynin in patients with OAB.8 A study in Asian patients also concluded that tolterodine was significantly more tolerable than oxybutynin.9
Additionally, dosing modifications may help minimize side effects. For example, dose titration or using an ER formulation are options for managing side effects.5
5. There is a common misconception that tolterodine cannot be used in men with concurrent benign prostate hyperplasia (BPH). Why is this incorrect, and what are your thoughts on this?
Historically, tolterodine was not administered to men with OAB and BPH because of concerns about antimuscarinics causing obstruction-induced urinary retention,10 despite men with BPH often presenting with comorbid OAB.11 However, the available evidence suggests that BPH worsens quality of life in men with OAB, and it has now been demonstrated that administering tolterodine to men with BPH is a reasonable method of treatment if symptoms have not been mitigated with classical α-adrenergic receptor-blocker therapy.11,12
6. How persistent are your patients on tolterodine, and what methods do you use to improve adherence?
Overall, achieving adherence to tolterodine treatment requires a level of trust, discussion and education between the clinician and the patient so that the patient understands what the expected outcome is and the possibility of treatment-related side effects.1 In an effort to facilitate this, patients are encouraged to keep a bladder diary to quantitatively measure urgency and the frequency of incontinence.1 Bladder diaries are not only essential for appropriately assessing the severity of symptoms, they can also be used as a tool to demonstrate treatment efficacy over time.1 Furthermore, bladder diaries can enhance patient feelings of bladder control, which improves the likelihood of adherence to treatment.
Combining tolterodine treatment with behavioural interventions, such as bladder training and a bladder diary, is essential to allow patients to objectively measure what is normal versus what is abnormal.1 Generally, patients learn that passing urine every 2 hours is considered to be normal,1 so the aim is to support the patient in reaching this goal by extending the time period between voidings over time. This training is particularly important as it allows for longer uninterrupted sleep, and psychologically reinforces an internal schema that they are no longer considered clinically incontinent.
1. American Urological Association/Society for Urodynamics and Female Pelvic Medicine and Urogenital Reconstruction. Diagnosis and treatment of overactive bladder
(non-neurogenic) in adults: AUA/SUFU guideline. Available at: https://www.auanet.org/common/pdf/education/clinical-guidance/Overactive-Bladder.pdf. Accessed 19 September 2016.
2. Mattiasson A, et al. BJU Int 2003;91:54–60.
3. Van Kerrebroeck P, et al. Urology 2001;57:414–421.
4. Esin E, et al. Aging Ment Health 2015;19:217–223.
5. Pfizer (Malaysia) Detrusitol SR Prescribing Information: 10 October 2012.
6. Siami P, et al. Clin Ther 2002;24:616–628.
7. Zinner NR, et al. J Am Geriatr Soc 2002;50:799–807.
8. Novara G, et al. Eur Urol 2008;54:740–763.
9. Lee JG, et al. Int J Urol 2002;9:247–252.
10. Loke YK, Singh S. Ther Adv Drug Saf 2013;4:19–26.
11. Eapen RS, Radomski SB. Rep Res Urol 2016;8:71–76.
12. Kaplan SA, et al. J Urol 2008;179(5 Suppl):S82–S85.